Page 40 - Journal of Structural Heart Disease - Volume 1 Issue 1

Commentary 34
cardiac surgeons alike.
Structural heart disease deals with a large anatom-
ical variation of many different cardiovascular struc- tures, with various shapes and locations and a multi- tude of possibilities on how to access. This demands a core-knowledge different than traditional interven- tional training, one that is not solely based on angi- ography but requires the complete physiologic and 3D anatomic understanding of cardiovascular struc- tures. The crux of the question remains: what is really needed to become a SHD Interventionist? Presently, there is no board certification in SHD, and no other formal or official guidelines for training. The majority of current specialists are trained by industry and “phy- sician proctors” on the specific use of each individual device and are familiar with the various aspects of catheter-based therapies. This includes intervention- al cardiologists, interventional radiologists, pediatric cardiologists, cardiac surgeons and vascular surgeons who may master one procedure but not another. Only 50% of the US training programs in coronary interventions provide some exposure to these types of procedures; in addition, there are only few centers (usually academic), which offer a formal, full year of designated SHD training [4-5]. In most cases, this training program is offered to candidates who have completed their full training in: a) internal medicine, general cardiology and interventional cardiology, b) general surgery and cardiothoracic surgery, c) pediat- rics and pediatric cardiology.
There is a consensus agreement among interven- tional cardiology training program directors that in the near future a training curriculum will be officially established and applied, as is the case with medicine, cardiovascular diseases and interventional cardiolo- gy [8-9]. At the moment, we only have some expert consensus recommendations on what would be re- quired for training [4-5]. Lately there have been also some recommendations on operator and institution- al requirements, but mostly for transcatheter valve repair and replacement [10-13].
What is certain is that the training should not con- sist solely on how to perform specific procedures by teaching on how to use any specific device. Such a curriculum will need to include, among others:
A. Master the anatomy, physiology, pathology and clinical patient management of SHD.
B. The development of technology and procedural skills of transcatheter therapy in SHD, and more importantly, to teach trainees to think outside the box. How to perform all kinds of access; know the type and performance characteristics of wires, catheters and devices.
C. Extensive training in all imaging modalities used at the diagnosis and treatment of SHD. This will include fluoroscopy, two-dimensional and re- al-time 3 Dimensional transthoracic (TTE) and trans-esophageal (TEE) echocardiography, int- racardiac echocardiography (ICE), 3D/4D Com- puted Tomography (CTA), Cardiac Magnetic Resonance imaging (CMR), Positron emission to- mography (PET scanning) and the use of Fusion imaging technology.
D. The team approach: Perhaps, one of the most im- portant aspects to be taught to trainees is learn- ing on how to work in a multidisciplinary team. SHD requires contributions from many experts and at all levels of patient care, from the diagno- sis and assessment to procedural performance. Like in the Apollo 11, success depends on the function of each team member.
At present, there is no official government budget for the training of SHD interventionalists. Usually, the costs of training are covered by their respective clin- ical departments or by industry grants. We believe that the time has come for full support, like other AC- GME programs, with the possibility for combined ef- forts with the Federal Government and Industry. Un- doubtedly, with increasing age of the population and the prevalence of SHD and the improving results in current SHD interventions, there will be a continually growing demand for the SHD interventionalist, and, optimistically, training standards and their means of financing. Finally, the Apollo 11 returned home, and remains until today a symbol of human victory. Let us hope that SHD procedures are another glorious human victory. We believe that these small steps are becoming now one giant leap the field of Structur- al Heart and that their respective procedures will be here to stay.
Journal of Structural Heart Disease, [Month Year]
Volume 1, Issue 1: 33-35